BR-Credentialing Auditor

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  • 17-00127
  • Direct Placement
  • Credentialing
  • Rancho Cucamonga, CA
Job Description
CLIENT COMPANY OVERVIEW
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For, "Favorite Training Program and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.

JOB TITLE
CREDENTIALING AUDITOR

DESCRIPTION
Under the direction of the Credentialing Manager, the Credentialing Auditor will conduct routine oversight, monitoring and auditing of all internal business functions within the company, as well as externally delegated functions to ensure compliance with all State, Federal and Accreditation standards.

  • Manage multiple concurrent audits plan audits and related projects, make judgments around objectives and scope and ensure effective and efficient audit execution.
  • Research regulations and inform various departments within the company and delegates of the company of any changes to regulatory requirements in relation to credentialing and re-credentialing requirements.
  • Conduct mock audits of department functions using audit tools and develop corrective action plans to address any identified issues.
  • Conduct pre-delegation audits for applicable areas for existing delegated entities and ensure that vendors continue to perform the delegated activities in accordance with the agreement.
  • Collect and summarize performance data, identify opportunities for improvement, and present findings to all applicable committees.
  • Develop, revise and maintain all audit tools to comply with state and federal regulatory requirements.
  • Participate in workgroups that address both clinical and non-clinical internal activities for which company must demonstrate improvement to meet its contractual requirements with the Center of Medicare and Medicaid (CMS), California Department of Health Services (Client), Department of Managed Health Care (DMHC), and other applicable entities.
  • Organize and administer a complex project plans for the achievement of organization and audit and oversight goals and objectives.
  • Assist in the formulation of policies and procedures, understand and interpret policies and procedures and regulations.
  • Serve as subject expert for assigned functional areas.
  • Ensure the privacy and security of Protected Health Information (PHI) as outlined in company policies and procedures relating to HIPAA compliance.

SKILLS & QUALIFICATIONS

  • Bachelor’s degree in Health Care or related field or equivalent work experience that would provide the knowledge of duties listed in lieu of degree.
  • 3+ years of demonstrated experience with credentialing oversight processes and credentialing and re-credentialing practices, preferably in a Managed Care setting.
  • Knowledge of Managed Care compliance for Medi-Cal or Medicare.
  • Valid driver’s license and automobile insurance. May be required to work away from the primary office 35% of the time or more.

COMPENSATION | POSITION CLASSIFICATION
Working for a premier health plan that is recognized and awarded for their Employee centric workplace culture, you will enjoy a competitive compensation and comprehensive benefits package valued at 35% of your annual salary.

  • Commensurate with Experience
  • Benefited | Full-Time | Exempt


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